Anal fissure presents with painful rectal bleeding and constipation, with pain occurring during and after defecation that is relieved between bowel movements. Examination typically reveals a tear in the posterior midline of the anus. Treatment involves topical anesthetics during examination, softening stools with psyllium, lubricating the anal canal with glycerin suppositories, and warm sitz baths for pain relief. Most acute superficial fissures will heal within a month with these conservative measures.

1. Anal fissure
Presentation
The patient complains of painful rectal bleeding and perhaps constipation. The pain
occurs with and immediately after defecation, and the patient is relatively
comfortable between bowel movements. Bleeding with defecation is usually slight,
only staining the toilet tissue. Mucus discharge may increase perineal moisture and
cause itching. Examination of anus reveals a radial tear or ulceration of the posterior
midline 95% of the time (the fissure is anterior in 10% of women but only 1% of
men). If the condition becomes chronic, distal edema may produce a "sentinel pile."
What to do:
• Provide topical anesthesia with lidocaine jelly or viscous lidocaine in order to
perform a reasonably comfortable rectal examination.
• Advise the patient to use psyllium seed supplements (e.g. Metamucil) to
soften stools and to use a glycerin suppository twice daily to maintain
lubrication of the anal canal.
• Instruct the patient to use warm, soothing sitz baths after each painful bowel
movement.
• Prescribe analgesics if needed.
• Inform the patient that an acute superficial fissure will take about one month
to heal. He should follow up if symptoms continue.
What not to do:
• Do not assume that a lesion located outside the anterioposterior midline
saggital plane of the anus is an anal fissure. Other possibilities include
ulcerative colitis, squamous cell carcinoma, leukemia, tuberculosis, syphilis,
herpes and trauma from instrumentation and anal intercourse.
• Do not confuse a "sentinel pile" with a hemorrhoidal vein.
Discussion
Pruritis ani has multiple etiologies. Infections such as pinworms, Candida albicans,
Tinea cruris and erythrasma can cause anal itching. Mechanical trauma from overly
vigorous cleansing of the perianal area may also cause pruritis and may be
aggrivated by diarrhea and by the presence of external or prolapsed hemorrhoids or
multiple skin tags which make cleansing more difficult. Another cause of pruritis ani
is allergic or contact dermatitis from agents such as soaps, perfumes in toilet tissue
and frminine hygene sprays as well as spicy foods, tomatoes, citrus fruits and colas,
coffee and chocolate. Other causes of pruritis ani include chronic anorectal disease
and cancer. If a specific cause of anal pruritis can be determined, then treat it
accordingly. If the etiology is obscure, the patient can be treated with hydrocortisone
cream to reduce itching and imflammation, followed by zinc oxide as a barrier cream.
The patient should be instructed to gently cleanse the anal area with a cotton ball

2. and a perineal cleansing lotion after each bowel movement, and should be directed
to obtain follow up care. A systemic anti-pruritic agent such as hydroxyzine (Vistaril)
50mg qid may be prescribed.